TRAUMA CARE IN ALASKA-2011 Frank Sacco MD, FACS Chair, Trauma System Review Committee
GOALS The scope of the problem. How best to care for seriously injured patients How we care for them now in Alaska How we can do better- examples Recommendations
Trauma in Alaska The leading cause of death under age 44. Alaska- second highest trauma mortality in the US 400-500 alaskans die each year. ~ 5000 hospital admissions. Over 1000 with permanent disabilty.
All Cause Mortality Alaska 10 Leading Causes of Death, Alaska 2005, All Races, Both Sexes Age Groups Ran All <1 1-4 5-9 10-14 15-24 25-34 35-44 45-54 55-64 65+ k Ages Congenita Unintentio Unintentio Unintentio Unintentio Unintentio Unintentio Malignant Malignant Malignant Malignant l nal nal nal nal nal nal Neoplasm Neoplasm Neoplasm Neoplasm 1 Anomalie Injury Injury Injury Injury Injury Injury s s s s s 4 3 13 47 54 55 104 163 419 732 15 Congenita Congenita Unintentio Malignant l l Heart Heart Heart Heart nal Neoplasm Suicide Suicide Suicide 2 Anomalie Anomalie Disease Disease Disease Disease Injury s 31 23 34 s s 71 111 405 627 13 2 2 1 Maternal Congenita Malignant Unintentio Unintentio Unintentio Pregnanc l Heart Cerebro- Homicide Homicide Homicide Neoplasm nal nal nal 3 y Anomalie Disease vascular 1 10 10 s Injury Injury Injury Comp. s 1 139 30 56 29 313 7 1 Chronic Chronic Malignant Low. Low. Short Heart Heart Cerebro- Homicide Neoplasm Suicide Respirator Respirator 4 Gestation Disease Disease vascular 1 s 26 y y 6 6 26 178 7 Disease Disease 26 117 Chronic Malignant Malignant Alzheimer' Low. Heart Liver Liver Cerebro- Homicide Neoplasm Neoplasm s Respirator 5 Disease Disease Disease vascular 2 s s Disease y 6 10 16 19 1 6 60 Disease 158 Chronic Necrotizin Low. g Cerebro- Diabetes Cerebro- Diabetes Diabetes Meningitis Respirator Suicide 6 Enter ocoli vascular Mellitus vascular Mellitus Mellitus 1 y 131 1 2 7 17 57 tis Disease 2 14 Congenita Unintentio l Diabetes Liver Diabetes SIDS Nephr itis Homicide nal 7 Anomalie Mellitus Disease Mellitus 2 2 6 Injury s 14 12 93 39 1 Congenita Influenza Influenza Alzheimer' Six Diabetes l Septicemi Cerebro- & & s 8 Tied Mellitus Anomalie a vascular Pneumoni Pneumoni Disease s a a 1 1 4 12 61 1 11 30 Six Pneumoni Three Three Liver Suicide Nephr itis 9 Tied tis Tied Tied Disease 9 28 1 1 2 5 52 Influenza Parkinson' Six Three Three Septicemi & s 10 Pneumoni Tied Tied Tied a Disease 1 2 5 7 a 22 44 M Produce WISQARS T d By: O ffic e of Stat ist ics a nd P rogramm ing, National Ce nte r f or Injury P rev ent ion a nd Cont rol, ion Ce nte rs f or Diseas e Cont rol a nd P reve nt Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System
Trauma Mortality in Alaska Age Adjusted Trauma Mortality 300 250 200 deaths/100,000 US 150 ALL ALASKANS ALASKA NATIVES 100 50 0 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 year
Trauma in Alaska Motor vehicle crashes leading cause of death. Firearm related injuries, second. 2009 hospital costs - Alaska trauma patients over $121 million. Medicaid & Workmans Comp 26 million hospital costs. (900 admissions) ~ 20% trauma admissions uncompensated.
Death from Trauma 50 45 40 35 30 25 20 15 10 5 0 Immediately Hours Days -Weeks
Trauma Systems A trauma system consists of hospitals, personnel, and public service agencies with a preplanned response to caring for the injured patient.
Trauma Systems “Getting the right patient to the right place in the right amount of time.’ Facilities (trauma center designation) Personnel (training) Patient transport Triage
Trauma Systems “15 -20% improvement in survival of the seriously injured.” NEJM 1999 Increase productive working years Improve statewide disaster preparedness. Inclusive systems -best
Trauma Systems Facilities-Trauma Centers Level I -Definitive subspecialty care, research. Level II – Definitive subspecialty care, surgery, orthopedics, neurosurgery. Level III- General surgery, orthopedics, no neurosurgery Level IV- Stabilization, limited or no surgical capacity
Trauma Systems- Training ATLS MDs, Midlevels TNCC Nurses RTTDC Rural MDs, Nurses, Prehospital PHTLS Prehospital ABLS Burn care ETT General public, Health aides
Trauma Systems- Transport EMS system Triage guidelines Injury protocols
Preventable Deaths: The impact of trauma systems 35 30 25 20 BEFORE trauma % system 15 AFTER trauma 10 system 5 0 San L.A. Tampa, Diego FLA
Trauma Systems & crash mortality Nathens et.al. 2000 18 16 14 12 10 PRE 8 POST 6 4 2 0 CA NY ILL FLA MA PA WA
Trauma systems & crash mortality Nathens et.al. 2000 8 6 4 2 0 -2 % -4 -6 -8 -10 -12 -14 Trauma Sys Restraint ETOH speed limit laws increase
Anchorage Mortality Rate 2005-2007 Excludes DOAs 5.0% 4.5% 4.0% 3.5% 3.1% 3.0% 130/ 4201 2.5% 2.0% 1.5% 0.8% 1.0% 20/ 2377 0.5% 0.0% Designated Non-Designated Alaska Trauma Registry (p<.01)
Designated vs Nondesignated Facilities- Anchorage Trauma Mortality Rates Status 1 Patients 35.0% 32.3% 32.2% 30.0% 25.0% 3 Year period 2004-2006 20.0% 16.8% 3 Year Period 2007-2009 15.0% 10.3% 10.0% 5.0% 0.0% Designated TC (ANMC) Non-Desgnated TC (PAMC/ARH) Design Non- ated Desgnated TC Designated TC (ANMC Non-Desgnated TC TC (ANMC) (PAMC/ARH) ) (PAMC/ARH) Deaths Total Patients Deaths Total Patients 3 Year period 2004-2006 16 156 86 266 10.3% 32.3% 3 Year Period 2007-2009 28 167 77 239 16.8% 32.2%
USA Trauma Center Growth Over Time 1991 1991 2002 2002 2009 2009 Level I 165 190 199 Level II 209 263 269 Level III 76 251 362 Level IV-V 21 450 748 Total 471 1,154 1,578 Pediatric Only 41 Courtesy Anthony Carlini ATS TIEP
Updated Trauma Center Status July 2009 Legend Level I # Level II " Level III-V ! ( Courtesy Anthony Carlini, ATS, TIEP
Alaska Trauma System- Beginnings 1993 statute- EMS authority for designating trauma centers created. Hospital participation voluntary. Standards for trauma center designation follow American College of Surgeons criteria. Outside review for Level I,II, and III
Current Status -18 Years Later T wenty – four hospitals in Alaska Verified / Designated 1 Level II ANMC 4 Level IV centers- NSH -MEH - YKHC – SCH 9 other facilities with reviews or consultations. Non-Verified 2 centers providing care for multiple trauma patients 6 centers that provide surgical capabilities 2 military hospitals
Alaska Trauma Facilities Alaska -Only state without a designated Level I or II trauma center (that serves the majority of the population . ) Anchorage - the largest city in the US without a designated Level I or II center (that serves the majority of the population.)
Insanity “Insanity is doing the same thing in the same way and expecting a different outcome” - Old Chinese Proverb
State of Alaska Dept of Health and Social Services: Trauma System Consultation November 2-5 2008 ACS-COT Site Visit Team Reginald A. Burton, MD FACS • Team Leader, Trauma Surgeon Jane Ball, RN, DrPH • ACS Consultant Samir M. Fakhry, MD FACS • Trauma Surgeon Holly Michaels • ACS Program Coordinator Drexdal Pratt, CEM • State EMS Director Nels Sanddal, PhDc, REMT -B • ACS Consultant James D. Upchurch, MD • Emergency Physician
Objective T o help promote a sustainable effort in the graduated development of an inclusive trauma system for Alaska. Multidisciplinary review of the trauma system 17 states have been reviewed
Executive Summary
Advantages & Assets Committed individuals who use their expertise every day to serve Alaska citizens Extensive networks for transport 3 large medical centers with extensive subspecialty expertise within the state Large Level I trauma center in Seattle which freely accepts adult and pediatric trauma patients
Advantages & Assets One center maintains ACS Level II verification standards (others have obtained consultations and are working toward verification.) Alaska Trauma Registry- all 24 acute care hospitals provide data. Injury prevention activities are well established. Initial efforts at legislative change.
Challenges and Vulnerabilities Public not aware of trauma system issues. Limited human resources. Few incentives for hospitals to participate. No statewide evaluation of system performance.
Executive Summary “Several Alaska Native facilities have sought and achieved verification and designation as trauma centers. …… To date few of the facilities serving the majority population have made a similar commitment to achieving nationally recognized standards of trauma care.” ACS-COT Alaska Trauma Systems Review 11/2008
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